Building A New Provider Network or Planning Your Next Service Area Expansion? Don’t Lose Sight of Your Biggest Asset

The sun is shining, kids are out of school, and vacation season is in full swing! While our Health Plan Network and Product teams are taking a few deep breaths after application and bid filing deadlines, we cannot rest on our laurels for very long. Summer is the best time to start planning your next service area expansion (SAE) or even your first step into the Medicare Advantage (MA) world. Maybe you are an established MA plan evaluating where to expand your geographic footprint. Maybe you are a Medicaid plan looking to expand into the Managed Long Term Services and Supports (MLTSS) arena and are wondering what it would take to have a Dual Eligible Special Needs Plan so many of the MLTSS Requests for Proposal (RFPs) are expecting; or maybe you are an Accountable Care Organization looking to leverage your infrastructure and enter the payer world. Perhaps, maybe, summer is the perfect time to start planning for your network needs. Plans need to be even more vigilant in managing their largest asset. Regardless of the size and scope of the organization, your plan’s network adequacy and accessibility is a cornerstone of any new initiative.

In today’s marketplace, it is no longer acceptable to meet the bare minimum Health Services Delivery (HSD) requirement. Consumers, and the Centers for Medicare & Medicaid Services (CMS), are demanding plans be able to offer choices that include quality and cost efficiency. With consumer-savvy, newly-aged-in Medicare beneficiaries, there is also a shift in patient expectations and what is available for their healthcare dollar. The new beneficiary is aging in from a world of patient engagement and incentive and reward programs and will expect the same level of service. Health plans need to find ways to evaluate their existing provider networks and newly expanded networks to meet these clinical and financial goals and be forward-thinking on how to best wrap risk adjustment and Star Ratings into the mix.

Additionally, the belt is tightening with day-to-day network management, and plans must reach out to their providers on a quarterly basis to confirm demographics and availability of their providers to ensure the information is updated in real-time with online directories and close the loop between the providers submitted on the HSD tables versus those in the directory. We will also delve into network adequacy and directory accuracy becoming part of the overall audit protocol pilot for 2016.

As we saw last year, many plans were unprepared to submit their entire network footprint in their SAE applications. The result was a scramble to fill gaps and re-evaluate if previously approved exceptions were, in fact, still valid. This requirement further supports the CMS commitment to monitor network adequacy for MA plans much more closely. It is time to set new network monitoring processes in place to ensure preparedness now.

At Gorman Health Group, we have a long history of providing the following:

  • Designing and developing a strong network strategy and provider engagement architecture that takes into account the quality, financial, risk adjustment, and Star Ratings goals needed for success within the competitive landscape of healthcare.
  • Direct contracting assistance to augment your staff to ensure contracting is done in an efficient and cost-effective manner.
  • The ability to do a deep-dive into a plan’s provider files to ensure your specialty mapping meets CMS standards and definitions for each category.
  • Run multiple network adequacy and availability scenarios.
  • Prepare your plans’ HSD tables for a CMS filing or prepare submission tables for a state or RFP filing.

Let us know how we can work and plan together now and build strategic network operations to support your plan’s goals for growth. Summer planning will allow us to ease into fall knowing we are prepared for the new season!



Gorman Health Group evaluates the design and delivery of high quality collaborative care while achieving compliance and improving revenue cycle management. Our multidisciplinary team of experts will assess the alignment of your products, your current network and your market to translate your business strategies into practical, efficient and rigorous work processes with the highest degree of compliance and accountability. Visit our website to learn more >>

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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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